Lay food and health worker involvement in community nutrition and dietetics in England: roles, responsibilities and relationship with professionals

Background Community‐based food initiatives have developed in recent years with the aim of engaging previously ‘hard to reach’ groups. Lay workers engaged in community nutrition activities are promoted as a cost‐effective mechanism for reaching underserved groups. The main objective of the study was to explore perceptions and definitions of lay food and health worker (LFHW) helping roles within the context of National Health Service (NHS) community nutrition and dietetic services in order to define the conceptual and practical elements of this new role and examine the interface with professional roles. Methods Interpretive qualitative inquiry; semi‐structured interviews with LFHW and NHS professionals employed by community‐based programmes, serving ‘hard‐to‐reach’ neighbourhoods, across England. A total sampling framework was used to capture all existing and ‘fully operational’ lay food initiatives in England at the commencement of fieldwork (January 2002). Findings In total, 29 professionals and 53 LFHWs were interviewed across 15 of the 18 projects identified. Although all 15 projects shared a universal goal, to promote healthy eating, this was achieved through a limited range of approaches, characterized by a narrow, individualistic focus. Lay roles spanned three broad areas: nutrition education; health promotion; and administration and personal development. Narratives from both professionals and LFHWs indicated that the primary role for LFHWs was to encourage dietary change by translating complex messages into credible and culturally appropriate advice. Conclusions This research confirms the emerging discipline involving lay helping within the NHS and community dietetics. The primary role of LFHWs in the 15 projects involved was to support existing NHS services to promote healthy eating amongst ‘hard to reach’ communities. The activities undertaken by LFHWs are strongly influenced by professionals and the NHS. Inherent to this is a fairly narrow interpretation of health, resulting in a limited range of practice.     

Toward an institutional perspective on social capital health interventions: lay community health workers as social capital builders

This article argues that social capital health research should move beyond a mere focus on social cohesion and network perspectives to integrate an institutional approach into the development of social capital health interventions. An institutional perspective, which is unique in its emphasis on linking social capital in addition to the bonding and bridging forms, contextualises social capital, allowing researchers to confront the complexity of social relationships. This perspective allows for the construction of interventions that draw on the resources of diverse actors, particularly the state. One intervention strategy with the potential to create community linkages involves lay community health workers (LCHWs), individuals who are trained to perform a variety of health-related functions but lack a formal professional health education. This article begins with a review of the institutional social capital-building literature. It then goes on to briefly review the social capital and health literature and discuss the state of intervention research. Thereafter, it describes LCHWs and discusses studies that have utilised LCHWs to tackle community health problems. In doing so, this article presents an institutional-based systematic framework for how LCHWs can build social capital, including a discussion of the ways in which LCHWs can successfully promote bonding, bridging and linking social capital.     

Lay conception of hypertension and its significance to clients and professionals in nutrition and health

Background In line with the Philippines' National Cardiovascular Disease Prevention and Control Programme, a study was conducted among young adults to determine their concepts and conceptualization of hypertension: its causation, prevention and consequences. Method Focus group discussions, conducted in the region with the highest prevalence of hypertension in the Philippines, 73 males and females were participated in the age group of 20–39 years, without medical history of the disease and with no training or employment in a health‐related field. Results Hypertension was perceived not as a discrete disease but interrelated with diseases having ‘blood‐origin’ and common signs and symptoms. It was conceptualized as having multiple causes, acting singly or in combination, with too little or too much food and physical activity as among the causal factors. Perceived pathways in its development were systematic and included both traditional and scientific biomedical concepts. Hypertension was considered a problem not only in the affected individual but also the family. Conclusion The concepts of hypertension of young adults are multidimensional, interconnected and linked to their day‐to‐day living. In thus conceptualizing the disease, they are able to make sense of it and, when respected by dietetic practitioners, provide guidance for improved communication. The introduction of scientific concepts of hypertension by nutrition and health professionals should draw from, inform and build on, existing lay perceptions.     

Rights‐based food and nutrition perspective: 21st century challenge for dietetics

Progress in addressing the problems of hunger and malnutrition has been slow and uneven across regions and countries of the world. A rights‐based perspective, not merely a utilitarian argument, must serve as the rationale for humans to be properly nourished. Rights impose corresponding binding obligations on others and the concept of rights holders and duty bearers goes beyond the human development paradigm. The right to adequate food is realized when every man, woman and child, alone or in community with others, has physical and economic access at all times to adequate food or means for its procurement. As duty bearers, governments are obligated to assure the realization of that right and accountable if the right is violated. The use of the human rights approach to adequate food necessarily implies a re‐examination and fundamental changes in the way we think about hunger and malnutrition and their causes; the manner of shaping and reshaping policies; the context and processes of planning, monitoring and evaluating programmes; and the substance and method of research and education in food and nutrition. Dietitians and dietetic associations can be instrumental in making the human right to adequate food a reality.     

The development, implementation, monitoring and evaluation of a food and nutrition policy within a local health plan

Local food and health policies were initiated in the UK in the early 1980s, and this paper traces developments in Leicestershire, England. The first policy was launched in 1987, which promoted the nutrition education messages of that time (less fat, more fibre and less sugar), primarily within the National Health Service. As a result of the publication of the Health of the Nation Green Paper in 1991, a local health plan was developed for Leicestershire, in which nutrition formed an integral part. Wider perspectives on nutrition have evolved reflecting the multidisciplinary approach to developing the Food and Nutrition Policy. In addition, updating of the nutrition messages in the local Food and Nutrition Policy has occurred to reflect the shift in emphasis towards nutritional adequacy and balance. The scope for implementation is now much wider, involving several key settings in the community, and there is an increased emphasis on monitoring and evaluation.     

An evaluation of a public health nutrition workforce development intervention for the nutrition and dietetics workforce

Background: Workforce development is a key element for building the capacity to effectively address priority population nutrition issues. On‐the‐job learning and mentoring have been proposed as strategies for practice improvement in public health nutrition; however, there is limited evidence for their effectiveness. Methods: An evaluation of a mentoring circle workforce development intervention was undertaken. Thirty‐two novice public health nutritionists participated in one of three mentoring circles for 2 h, every 6 weeks, over a 7‐month period. Pre‐ and post‐intervention qualitative (questionnaire, interview, mentor diary) and quantitative (competence, time working in public health nutrition) data were collected. Results: The novice public health nutritionists explained the intervention facilitated sharing of ideas and strategies and promoted reflective practice. They articulated the important attributes of the mentor in the intervention as having experience in and a passion for public health, facilitating a trusting relationship and providing effective feedback. Participants reported a gain in competency and had an overall mean increase in self‐reported competence of 15% (range 3–48% change; P < 0.05) across a broad range of competency elements. Many participants described re‐orienting their practice towards population prevention, with quantifiable increases in work time allocated to preventive work post‐intervention. Conclusions: Mentoring supported service re‐orientation and competency development in public health nutrition. The nature of the group learning environment and the role and qualities of the mentor were important elements contributing to the interventions effects. Mentoring circles offer a potentially effective strategy for workforce development in nutrition and dietetics.     

Relevance of food‐based dietary guidelines to food and nutrition security: A South African perspective

Food‐based dietary guidelines are often developed at country level to assist in bringing dietary intakes closer to nutrient intake goals and, ultimately, to prevent nutrition‐related diseases. However, high food prices, alongside growing inflation, increasingly restrict food choices. This can leave those who are already vulnerable and less well off more exposed to the associated health implications of a nutrient deficient diet. With food and nutrition security being a high priority on the global nutrition agenda, this paper explores the feasibility of food‐based dietary guidelines to assist in improving food and nutrition security, focusing on nutritionally vulnerable groups in South Africa. It is argued that increased food prices, together with population growth, urbanisation and inflation, constrain everyday healthy food choices of a large proportion of South Africans. The South African food‐based dietary guidelines released in 2012 advocate the consumption of a daily diet containing a variety of foods. Unfortunately, even when the most basic and low‐cost food items are selected to make up a recommended daily diet, the associated costs are well out of reach of poor individuals residing in South Africa. The average household income of the poor in South Africa equips many households to procure mainly low‐cost staple foods such as maize meal porridge, with limited added variety. Although the ability to procure enough food to maintain satiety of all family members might categorise them as being food secure, the nutritional limitations of such monotonous diets may have severe implications in terms of their health, development and quality of life. Food‐based dietary guidelines alone have little relevance in such circumstances where financial means limit food choice. Alternative interventions are therefore required to equip the poor to follow recommended healthy diets and to improve individual food intake and nutrition security.     

Taste the difference, make the difference: the role of a public health nutritionist in the UK food retail industry and a rural community in Zambia

Summary  Nutritionists and Dietitians have an important role to play in enabling populations to improve their health. Using examples from a UK food retailer and rural community in Zambia, this article highlights the importance of developing strong partnerships which support sustainable community-based activities that promote healthier practices at the individual, family and community levels.     

Community nutrition and dietetics: a survey of nutrition group members in 1995

In 1995 the Community Nutrition Group (CNG) of the British Dietetic Association (BDA) celebrated its 21st birthday. Enormous development in community nutrition and dietetics has taken place in these 21 years. Membership of the CNG now stands at 493, representing 12% of the membership of the BDA. In December 1995 a questionnaire was sent to all members of the CNG, of whom 73% completed the questionnaire. Information collected included work structures; aspects of work which had increased or decreased during the past 5 years and the proportion of time allocated to specific community nutrition activities. The results show that there has been an increase in the number of dietitians working in the community (average reported increase of 1.78 whole time equivalents). The main area of growth has been in all aspects of primary care (clinical, health promotion and training). Other areas of growth include community clinical work, training, health promotion and community development. The concern that the nutrition facilitation role of the dietitian in the community is being dominated by clinical work is not supported; 51% of CNG members>> time is spent in nutrition facilitation, 37% in clinical work. Dietitians working in the community must continue to work to demonstrate the effectiveness of their nutrition facilitation role to secure continued funding.     

Consumer involvement in health care purchasing: the role and influence of the community health councils

Recent reforms in the National Health Service (NHS) place great emphasis on the importance of the ‘voice of the consumer’ in the provision of health care. Health purchasers are now required to adopt the role of ‘champion of the people’, traditionally that of the Community Health Councils (CHCs). In turn the CHCs have been encouraged to become more closely involved in the purchasing process. This paper draws on a national investigation of the operation of CHCs in order to examine the response of both the Councils and local purchasers to these developments. For many CHCs pressures for greater involvement may clash with their concern to retain an independent stance. This paper examines how closely CHCs are currently working with local purchasers and explores the central question of whether those prepared to work more collaboratively with their Health Authorities (HAs) are likely to have greater impact on purchasing decisions. The paper concludes that, while some CHCs are more closely involved than others, few perceive that they exert much real influence over the decision-making process. Councils share a general view that major purchasing decisions are increasingly being made without the opportunity for scrutiny by them or the wider public.     

营养健康教育对广州市小学生食品认知的影响

目的 了解广州市小学生对食品认知的现状,评估营养健康教育的效果,为促进广州市小学生健康的饮食行为和改善营养健康状况提供依据。方法 选取广州市15所小学1 608名高年级小学生为研究对象,实施为期8周的营养健康教育,并于干预前后进行对食品认知的调查。结果 广州市小学生对食品属性的整体知晓率为72.09%。营养健康教育干预后小学生对合理营养知识的整体知晓率上升到85.26%,差异有统计学意义(χ²=82.584,P<0.05)。结论 广州市小学生对食品认知的水平较低,存在一定的误区。营养健康教育能明显提高小学生对食物属性的知晓率。     

Qualitative research in nutrition and dietetics: assessing quality

In recent years, qualitative research has become much more widely used in healthcare settings and undoubtedly has much to offer nutrition and dietetics. Its value is, however, still sometimes called into question and, for those unfamiliar with qualitative approaches, it can be difficult to grasp what distinguishes ‘good’ qualitative research from that which has been less rigorously conceived and conducted. This review, the fourth in the series, aims to highlight some of the key scientific debates around the quality criteria that can be applied to qualitative research, and offers some flexible guidelines that may be used both in producing and assessing qualitative health research, including studies in nutrition and dietetics. Other reviews in this series provide a model for embarking on a qualitative research project in nutrition and dietetics, an overview of the principal techniques of data collection, sampling and analysis and some practical advice relevant to nutrition and dietetics, along with glossaries of key terms.     

Attitudes to food and nutrition policy from five different sectors in Australia

This study attempted to examine the views of representativesof five sectors of the Australian food and nutrition systemabout ways in which consumers' nutrition status can be strengthened.The study was conducted in two stages: stage one was in theform of a postal Delphi survey in which 56 representatives drawnfrom the farming, food processing, regulatory, food safety andnutrition sectors were asked to suggest ways to improve theAustralian food sytem. These results were summarised in theform of a short 64 item opinion statement inventory. In stagetwo this was completed (via postal administration) by 253 representativesfrom the same five sectors. The findings show that there waswidespread support for policy proposals to do with educationand enforcement of current regulations. However, there werealso major differences between the groups. Multidimensionalscaling and discriminant analytic approaches showed that foodprocessors and regulators tended to hold views supportive ofthe present status quo, whereas nutritionists and, to a lesserextent, farmers and food safety personnel supported changesto the system. The possible causes of these differences arediscussed along with the implications of the findings for theimplementation of the Australian food and nutrition policy.     

Qualitative research in nutrition and dietetics: data collection issues

The wide scope of qualitative enquiry presents the researcher with a number of choices regarding data collection and sampling. Selecting data collection and sampling techniques can therefore be somewhat daunting, particularly because, often, there is no single, universally accepted ‘correct’ option. Appropriate research methods are, however, crucial to ensure high‐quality research. This review, the second in the series, provides an overview of the principal techniques of data collection and sampling that may be used for qualitative research in nutrition and dietetics. In addition, it describes a process for choosing appropriate data collection and sampling methods that considers the extent to which they provide data that answers the research question(s) and are compatible with the philosophical assumptions about ontology, epistemology and methodology that underpin the overall design of a study. Finally, it discusses the central role that the researcher plays in qualitative data collection and encourages researchers to acknowledge and reflect upon their impact on the data. Other reviews in this series provide a model for embarking on a qualitative research project in nutrition and dietetics, an overview of the principal techniques of data analysis and quality assessment of this kind of research, and some practical advice relevant to nutrition and dietetics, along with glossaries of key terms.     

Challenges facing community health workers in Brazil's Family Health Strategy: A qualitative study

Community health worker (CHW) programs are implemented in many low‐ and middle‐income countries such as Brazil to increase access to and quality of care for underserved populations; CHW programs have been found to improve certain indicators of health, but few studies have investigated the daily work of CHWs, their perspectives on what both helps and hinders them from fulfilling their roles, and ways that their effectiveness and job satisfaction could be increased. To examine these questions, we observed clinic visits, CHW home visits, and conducted semistructured interviews with CHWs in 7 primary care centers in Brazil—2 in Salvador, Bahia, and 5 in São Paulo, SP—in which CHWs are incorporated into the work of all primary care health teams. In addition to enhancing communication between the medical system and the community, CHWs consider their key roles to be helping persuade community members to seek medical care and increasing health professionals' awareness of the social conditions affecting their patients' health. Key obstacles that CHWs face include failure to be fully integrated into the primary care team, inability to follow‐up on identified health needs due to limited resources, as well as community members' lack of understanding of their work and undervaluing of preventative medicine. Increased training, better incorporation of CHWs into clinic flow and decision making, and establishing a clear community awareness of the roles and value of CHWs will help increase the motivation and effectiveness of CHWs in Brazil.     

Early nutrition and adult health: Perspectives for international and community nutrition programs and policies

Recent economic changes throughout the world, either development or crises and recessions, have prompted a host of nutrition related problems, including a decreased prevalence of undernutrition, an increase in the prevalence of diet related diseases, widespread food insecurity as crop prices increase, and so on. In addition, evidence is mounting that suggests that exposure to poor nutrition early in life is a predisposing factor for chronic diseases in adulthood. Thus, the role of international or community nutrition professionals is vital to not only studying and understanding the interplay between economics, food policy, and health, but also to improving the ability to intervene and prevent many problems related to food insecurity in developed and developing countries. The purpose of this review is to outline and describe these issues as a means to open discussion on how to best alleviate major nutrition problems in the world.